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APPLICATION FOR SANITATION PERMIT Permit No3Z3___4_.. <br /> - <br /> ` (Complete in Duplicate) y , <br /> Date Issued -7----'-5-. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATIO ----- <br /> ----------------------------------- <br /> Owner's Name----------------- +�,�)'1 ---------------------- <br /> Phone <br /> Address_-......... <br /> - <br /> Contractor's Name </ <br /> Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other,❑ s <br /> Number of living units: _-/--- Nu r of bedrooms Y__ Number of baths -l--_-_ Lot size ------/ _-- ----- -------------- <br /> Water Supply:' Public system Ejo<oinmunity system ❑ Private ❑ Depth to Water Table,-0 ft. <br /> C <br /> Character of soil to a depth of 3 feet: Sand ❑ Gr vel ❑ Sandy Lo;�50 <br /> C -Loam ❑ Clay E] Adobe ardpan El <br /> Previous Application Made: Yes ❑ No ew Construction: Yes � <br /> 1 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: _ <br /> . .{No septic tank or cesspool permitted if public sewer is available within 200 feet.} ! s c h <br /> Septic Tank: t Distance from nearest well-----------------Distance from foundation--------------------Material-___ -------------_- y <br /> ❑ o. of compartments-- --------- --/-----------5 z -------------•---------------Liquid depth--------------------------Capacity........ <br /> k <br /> Dis sal laid: Distance from near welll.l'/ Istance from foundation -_ <br /> p � A /,14_- --_---.Distance to nearest lot ine--S-___-- <br /> Number of lines------ ----- en th of each line___---- I <br /> --- g _G�/rr-----------.Wid+h of trench------------ l------- -------- <br /> or``' <br /> Type filter material --- �i)e th of filter material--- Total length_-___-_--�-e <br /> fJ YP / p [� <br /> Seepage Pit: Distance to nearest well--------------- ------Distance from foundation--------------------Distance to nearest iot line_-------------..- <br /> ❑ Number of pits-----=---- -----------Lining material---------------------- Size: Diameter----------------------------------------- Depth------ -------------------------- l <br /> (Distance from nearest well-----------------Distance from foundation-------------_ -_-..Lining material-- <br /> Cesspool:El <br /> Size: Diameter-------------------- ..--.---Depth------------- ---------------------Li u;d_ Ca—Cap --gals. <br /> Privy: Distance from nearest well-----_______­----------------------------------Distance from nearest building.---_____-------------_------__.__.--.-. <br /> ❑ Distance to nearest lot line---------- ---- ------- ----- -- -- • - - ------------- -------------------- = <br /> -R--e--m---o--d--e--l-in-- <br /> emodeling--a--n-d--/--o- <br /> nd/or repairing (describe) --------- ------- -- ------- <br /> - <br /> o <br /> -------------------------•------------------------------------•-------- -------- ------------------- <br /> f' ------- -- <br /> ---- - ------ <br /> ------------------------------------------------------------ --------------------------------------------------------- -- ------------------------------------------------------------------------------------------------- <br /> I hereby certify that I have prepared this application and that work will be done in accordance with San Joaquin County <br /> ordinanceseZZli, <br /> State laws and rules nd gulations of the San Joa uin Local Health Distr'ct. <br /> 00 <br /> r <br /> 0 <br /> {Signed}_-- (�_ _ -{Owner nd/or tractor) <br /> -4--- d --------------------------------------------------------------- <br /> ------ --- - Tale <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc.; can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------' ---------------=-------------- ---------------------------------------- DATE--- �------------------ ----- <br /> REVIEWEDBY -- ---------.-------------------------------------------------------------------- DATE----- - ------- •---------------------------------------- <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------- <br /> Alterationsand/or recommendations-------------------------------------------------------------------------------------------------------------------------------------------..-------_---------- <br /> --------------------------•-•------------•-----....-.------=----------------------- --------------------------------------------- -------•----------•------------ ------------------..-------------------------- <br /> ---------- <br /> 4 <br /> -------- <br /> ------------------------------------------- ------------ ------------•------------------------------------------••----------------------------- --- --------------•---------------- r <br /> I} <br /> FINAL INSPECTION BY------------- ------ � E Date . <br /> � [�i. '_ 4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Stree+ 300 West Oak Street 132 Sycamore Street 814 North "C" Street I <br /> Stockton, California Lodi. California Manteca, California Tracy, California <br /> •1 <br /> I <br /> SES-9-2M I0-52 Revised W-2100 <br />